Detection and management of diabetic glomerulopathy in children and adolescents with insulin-dependent diabetes mellitus: Need for improved knowledgeand better care

Current modalities of detection and management of incipient diabetic nephro pathy in childhood and adolescence are summarized and the open questions ou tlined. In particular, the predictive value of microalbuminuria for later n ephropathy in adolescents is examined. Microalbuminuria is not as strong a predictor as suggested in earlier studies - recent studies show up to 50% o f microalbuminuria can revert to normal, We advocate that the association o f well-established risk markers and promoters of renal injury, including de gree and tracking of albuminuria, glycemic control, blood pressure changes, incipient retinopathy and genetic background, allow more precise assessmen t of the individual risk of developing nephropathy and the decision to star t pharmacological intervention. The major impact of strict glycemic control to prevent the development and progression of diabetic nephropathy is emph asized, as well as the need for a multidisciplinary team to optimize the ca re of pediatric diabetic patients. We discuss other therapeutic options, i. e. angiotensin-converting enzyme inhibitors (ACE-Is), moderate dietary prot ein intake, and other drugs. ACE-Is may provide a second line intervention in a well selected, high-risk subgroup of microalbuminuric diabetic adolesc ents.